RN Case Manager - Utilization Review

At The CORE Institute, we are dedicated to taking care of you so you can take care of business! Our robust benefits package includes the following:

• Competitive Health & Welfare Benefits
• Monthly $43 stipend to use toward ancillary benefits
• HSA with qualifying HDHP plans with company match
• 401k plan with company match (Part-time employees included)
• Employee Assistance Program that is available 24/7 to provide support
• Employee Appreciation Days
• Free Lunch Fridays
• Closed Holidays

Key Responsibilities:

A Case Manager/Utilization Review Nurse, in collaboration with patients/families, physicians and the interdisciplinary team, provides leadership and advocacy in the coordination of patient-centered care across the continuum to facilitate optimal transitions and progression in care.

• Conduct concurrent and retrospective reviews of patient medical records to verify the medical necessity of services provided.
• Assess admission criteria and length of stay, applying standardized clinical guidelines such as InterQual or MCG to justify care levels.
• Issue pre-authorizations for procedures, medications, and durable medical equipment by providing clinical information to insurance carriers.
• Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies.
• Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement.
• Identify and refer cases to case management or social work for complex discharge planning needs.
• Prepare and submit clinical appeals to insurance companies when services are denied, providing documentation to support medical necessity.
• Track and analyze utilization data to identify trends in resource use, care delays, and claim denials for reporting purposes.

EDUCATION

• Associate Degree in Nursing (ADN) required,
• Bachelor of Science in Nursing (BSN) preferred.

EXPERIENCE

• Three to five years of clinical experience in a direct patient care setting within an acute care hospital required.
• Previous experience in case management or utilization management required.

REQUIREMENTS

• A current and unrestricted Arizona Registered Nurse (RN) license.
• Certification in Health Care Quality and Management (HCQM) or as a Certified Case Manager (CCM) credential preferred.

KNOWLEDGE

• Medical Necessity Analysis: This skill involves a detailed evaluation of patient medical records. The nurse must critically assess the documented clinical information to determine if the proposed treatments, procedures, and services are medically appropriate and necessary according to established standards.
• Payer-Provider Liaison: Acting as a crucial communication link, the nurse must effectively mediate between healthcare providers and insurance payers. This requires translating clinical information into the language of insurance requirements to resolve discrepancies and pre-emptively address potential denials.
• Utilization Data Interpretation: This involves collaborating with the Revenue Cycle Management (RCM) team to analyze utilization data to spot trends, such as patterns in claim denials, delays in care, or inefficient use of resources. This analysis helps inform process improvements and strategic reporting within the healthcare facility.

SKILLS

• Patient Assessment: Conduct comprehensive assessments of patients' medical, emotional, and social needs to develop individualized discharge plans that ensure continuity of care.
• Care Coordination: Collaborate with healthcare providers, including doctors, nurses, and therapists, to create an integrated plan of care that addresses clinical needs, equipment, home care, and other requirements.
• Discharge Planning: Determine the appropriate discharge disposition based on factors such as living situation, mobility, cognitive status, and available support systems. This includes deciding whether patients can return home with services or require care in a facility.
• Arranging Services: Coordinate necessary post-discharge services, such as home health care, rehabilitation, and durable medical equipment, ensuring that these services are in place before the patient leaves the hospital.
• Communication: Maintain clear communication with all parties involved in the patient's care, including insurance providers, to secure coverage for post-discharge services and ensure that receiving providers are informed of the patient's needs and changes in their condition.
• Clinical Guideline Application: Applying standardized clinical criteria, such as InterQual or MCG, is a core function. This involves interpreting complex medical information and using these evidence-based guidelines to objectively justify admission, continued stays, and the appropriate level of care.

ABILITIES

• Ability to work in a high-stress, fast-paced environment.
• Ability to develop relationships with providers, staff, patients, families, and payors.
• Ability to work cooperatively and professionally in a team environment.